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Part C„ Prior/Pending Bankruptcy Cases
Has a bankruptcy case been filed by you or against you in the last 8 years? □ No □ Yes
If yes, in which district of which state was the case filed?_____________________________
Case Number:________________________ Date filed:_____________________________
Are there currently any bankruptcy cases pending against you, your business, your spouse, or your spouse’s business? □ No □ Yes
If yes, name of debtor:_________________ Relationship to you:______________________
Case Number:________________ Date filed:____________ Judge: ____________________
In which district of which state was the case filed?___________________________________
Exhibit “C” to the Voluntary Petition
Do you own or have possession of any property that poses or is alleged to pose a threat of imminent and
identifiable harm to public health or safety? □ No □ Yes (if yes, please attach a list and description of the property.)
Debtors Who Reside as Tenants of Residential Property
If you rent your home, does a landlord hold a judgment against you? □ No □ Yes
if yes, please provide the name and address of the landlord:
Name:____________________________________________________________________
Address:__________________________________________________________________
_________________________________________________________________________
City:___________________________ State:________________________ Zip: __________
English to Spanish translation
Client Questionnaire For Non-Business Debtor
Section 1 Basic Information Part A. Name and Address
Name: ______________________________________________________________________
Last First Middle
Telephone Number Home:______________________________ Work:____________________
Have you used any other names in the past eight years? □ No □ Yes If yes, list other names:
Social Security Number:______________ -_________ -__________________
Address: ________________________________________________________________________________
City: _______________________________ State:_______________ Zip:_________________
County: ________________________
Have you lived at this address for at least 180 days? □ No □ Yes
Have you lived at this address for at least 730 days (2 years)? □ No □ Yes
If you answered no to either of the questions above, please list your previous address:
Address:__________________________________________________________________________
City: _____________________________ State:_____________ Zip:_____________________
County:__________________
If you have a different mailing address, please list: Mailing Address:
City: _____________________________ State:_____________ Zip:_____________________
Part B. Name and Address of Spouse
If you are filing jointly with your spouse, fill in the following information about your spouse:
Name: ______________________________________________________________________
Last First Middle
Has your spouse used any other names in the past eight years? □ No □ Yes If yes, list other names:
Social Security Number:______________ -_________ -__________________
Address: (if different from your address):
______________________________________________________
City: _____________________________ State:_____________ Zip:_____________________
County:___________
If your spouse has a different mailing address, please list:
Mailing Address:________________________________________________________________________
City: _____________________________ State:_____________ Zip:_____________________
8:00 AM – 12:00 Midnight
